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Antimicrobial Stewardship in Post Acute Care
Houston Antimicrobial Stewardship Symposium, March 5, 2015 Beth Weisz PharmD, MHA PharMerica HD/Kindred Healthcare
Topics
• Kindred/PharMerica Antimicrobial Stewardship Program
• Evolution of the Antimicrobial Stewardship Program • Successes in Antimicrobial Stewardship • Continued opportunities/ barriers to Antimicrobial
Stewardship • Transitions of Care and Antimicrobial Stewardship
Kindred Healthcare/PharMerica
• Kindred Healthcare is a multi-facility health-care corporation providing post-acute services.
• Service across the care continuum – Transitional Care Hospitals (LTACH) – Sub Acute Units – Nursing and Rehab – Home Care and Hospice
• PharMerica Hospital Division provides pharmacy management services to Kindred Hospital Division
• Partnership to provide Clinical, Operational and Regulatory support for Kindred both locally and nationally
Kindred Antimicrobial Stewardship
• In late 2009 a Hospital Division wide Antimicrobial Stewardship Program was initiated within Kindred Healthcare
• The initiative was developed within corporate Pharmacy Advisory Committee (PAC)
• Measures and Modalities used in the program have evolved since 2009.
• Multiple resources and tools have been created to assist hospitals with the initiative
• Early focus on education, with concurrent audit and feedback via an AS Team
Antimicrobial Stewardship
“Awareness for all Clinical Staff”
2009
Pharmacy Standards Committee Kindred/PharMerica
Kindred Antimicrobial Stewardship
• August 2009 education for Directors of Pharmacy – What is AS? – How to start an ASP
• 2010 began tracking AS metrics – Patients receiving antibiotics >10 days – Patients receiving >3 antibiotics – Cost of antimicrobials per patient day
Kindred Antimicrobial Stewardship • 2012 review of Antimicrobial Stewardship
Program outcomes • Survey to Directors of Pharmacy to assess
status of AS in the hospitals – Barriers Identified
• Time to gather data (manual processes) • Lack of lab data • Physician leadership • Lack of staff knowledge
– Successes Identified • Improved durations and documentation • Increased collaboration • Reduced costs • Improved susceptibilities • Improved lab results
Kindred Hospital Outcomes • Early Data
– Operational Outcome- Antibiotic Spend ppd – Quality Outcome- >3 Antibiotics, >10 days therapy – Data collection challenges- manual process/inconsistent
reporting
CALENDAR YEAR >3 antibiotics >10 days therapy
Total Antibiotic Spend ppd
Baseline data 3rd qtr 2009 3.2 5.7 $34.90
2010 3.38 4.97 $32.78
2011 4.04 6.20 $33.57
Kindred Antimicrobial Stewardship
• Pharmacy Advisory Review of AS data – Are we using the right metrics?
• >3 drugs • > 10days • Cost
– Are we using the right methods? • Education
– Who should we target for education? • All providers
– Have we been successful? • We can do more
Kindred Antimicrobial Stewardship
• Metrics – Quality – current metric doesn’t work, what should we be
reporting? • Appropriate therapy is sometimes subjective • Protocol adherence- Did not have established protocols • Resistance patterns- varied lab reporting, lack of antibiogram
data • Reduced HAI- data was not available at the time
– Operational outcomes cost- Improvement seen, but data collection was manual and inconsistent
Antimicrobial Stewardship Subcommittee
• Subcommittee of our corporate Pharmacy Advisory Committee
• Formally established in late 2012 • Working group to develop training tools and
resources for Antimicrobial Stewardship as well as review utilization and trends
• Membership includes- Kindred DOPs, Kindred Infectious Disease Physicians, Kindred Laboratory and Infection Control Leadership, Kindred Pharmacy Leadership, other Clinical Content experts- CDC, clinical pharmacy, IT, MedAssets
Kindred Healthcare AS Manual
• Section 1- Overview of Antimicrobial Stewardship concepts • Focus on the 6 D’s • Marketing Antimicrobial Stewardship at your hospital • Enforcing sound infection control practices
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Kindred Healthcare AS Manual • Section 2 Treatment Guides
– Designed to provide specific guidance and recommendations regarding common infections seen in the transitional care environment
• Section 3 Antimicrobials with Indications and Restrictions Defined – Carbapenems, Tigecycline, etc…
• Section 4 Important Pharmacokinetic Principles – Education around basics of Pharmacokinetics and renal dosing – Extended infusion guidance
• Section 5 Infection Control Principles – Review of infection principles related to antimicrobial stewardship – Evidence based bundles for management of Central lines, urinary
catheters, and mechanical ventilation
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Kindred Healthcare AS Manual
• Section 6 Laboratory Recommendations – CDC based guidance on ordering of cultures
• Section 7 Antibiograms – How to read and use
• Section 8 Antimicrobial Stewardship Resources • Section 9 Case Studies and Post Test
– Physicians, pharmacists, nurses
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Improving Antimicrobial Therapy, Providing Tools & Resources: The Antimicrobial Stewardship Manual Ask the I.D. Experts webcast Dialogues on Contemporary ID Issues in Transitional Care
Presenters: David Hines, M.D. FACP Diane Rhee. Pharm D.
Kindred Hospital Outcomes
CALENDAR YEAR TOP 3 Antibiotics spend ppd
Total Antibiotic Spend ppd
2012 18.42 30.53 2013 17.71 30.52
2014 16.64 26.53
Estimated Savings with AS in 2014 $4,972,401
•Operational Measure- Antibiotic Costs Per Patient Day(PPD) CALENDAR
YEAR >3 antibiotics >10 days
therapy Total Antibiotic Spend ppd
2010 3.38 4.97 $32.78
2011 4.04 6.20 $33.57
Kindred Success Hospital Case Study
•Hospital System in Southern California •History of high anti-infective costs •Clinical pharmacy coordinator hired in early summer •Boots on the ground •Primary focus on anti-infectives • Antimicrobial Stewardship program re-launch Mid August •Concurrent audit and feedback
Anti-infective Cost PPD 2014 Impact of Clinical Pharmacist and Active AS Program
$52.70
$35.00
$47.33
$42.55
$38.76
$20.00
$30.00
$40.00
$50.00
$60.00
August September October November December
A reduction in AB cost from $52.70 to $38.76 represents an annualized reduction in cost of over $265,000
TARxGET Rx data, (ABC): Graphs do not reflect contract increases in 2014; savings is understated
Continued Opportunities • AS Implementation varies across our hospitals.
– Varied implementation of formal AS teams – We see success in hospitals with physician,
pharmacist, ICP rounds/meetings at least weekly – Need to continue to share Best Practice/Processes
Continued Opportunities • Pharmacist and Provider Education is needed
– Decision trees in development – AS manual updates on-going – Kinetics protocols established – Boots on the ground model expansion
• Physician Champion identification is key • Guideline and protocol adherence as a Quality
metric – P&T Dashboard 2015- micafungin – Scorecards- guideline adherence-daptomycin
• Restriction is used in some hospitals with success
Continued Opportunities
• Lab – Microbiology Interventions varies based on lab provider – Antibiogram availability underway – Appropriate ordering of cultures – Reflex orders for cultures and sensitivities
• Infection Control – Chlorhexidine bathing – Cohorting patients and staff assignments based on local
prevalence – Screening on admission (CRE) based on local rates.
• Clinical Decision Support • Auto-stop/ review process for all antimicrobials
Continued Opportunities/Transition of Care and Antimicrobial Stewardship • Applies to the entire Post Acute space- LTACH, SAU,
etc.. • Communication and Collaboration are Critical to
appropriate continuation of therapy. • We need to know
– Diagnosis – Plan for continuation of therapy – Anticipated duration – Cultures – Antibiotic therapy history
Continued Opportunities/Transition of Care and Antimicrobial Stewardship • Vancomycin treatment failure?
– LTACH are able to continue vancomycin therapy if that is the appropriate therapy
– Labs are evaluated routinely – Kinetics protocols are in place
• Osteomyelitis – What is the intended duration of therapy? – Acute versus chronic infection – Is surgical intervention a consideration?
Conclusion
• Kindred has identified local and national AS successes in both operational and quality metrics.
• There are some unique challenges to AS in the post acute space but many of the barriers to AS are the same across the healthcare continuum.
• Collaboration and effective communication are critical components to provision of quality care.
Questions?